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BACKGROUND: The surgical treatment of complex anal fistulas is very challenging because of the incidence of incontinence and recurrence after traditional approaches. Video-assisted anal fistula treatment is a novel endoscopic sphincter-saving technique.

OBJECTIVE: The aim of this article is to evaluate the results of treating complex anal fistulas from the inside and to focus on the rationale and the advantages of this innovative approach.

DESIGN: This is a retrospective observational study.

SETTINGS: The study was conducted at a tertiary care public hospital in Italy.

PATIENTS: From February 2006 to February 2012, video-assisted anal fistula treatment was performed on 203 patients (124 men and 79 women; median age, 42 years; range, 21–77 years) who had complex anal fistulas. One hundred forty-nine had undergone previous anal fistula surgery.

INTERVENTIONS: Video-assisted anal fistula treatment has 2 phases: diagnostic and operative. The fistuloscope is introduced through the external opening to identify the main tract, possible secondary tracts or abscess cavities, and the internal opening. With the use of an electrode, the fistula and its branches are destroyed under direct vision and cleaned. The internal opening is closed by a stapler or a flap. Half a milliliter of synthetic cyanoacrylate is used for suture reinforcement.

MAIN OUTCOME MEASURES: Successful healing of the fistula was assessed with clinical evaluation. Continence was evaluated by using patient self-reports of the presence/absence of postdefecation soiling.

RESULTS: Follow-up was at 2, 4, 6, 12, and 24 months. The 6-month cumulative probability of freedom from fistula estimated according to a Kaplan-Meier analysis is 70% (95%CI, 64%–76%). No major complications occurred. No patients reported a reduction in their postoperative continence score.

LIMITATIONS: The limitations of this study included potential single-institution bias, lack of anorectal manometry, and potential selection bias.

CONCLUSIONS: Video-assisted anal fistula treatment is effective and safe for the treatment of fistula-in-ano.